- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.17 / $2.17 / $2.17
| Professional | | $2.17 | $2.17 | $2.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.95 / $3.95 / $3.95
| Facility | | $3.95 | $3.95 | $3.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.41 / $3.41 / $5.47
| Professional | | $3.41 | $3.41 | $5.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.97 / $5.20 / $5.20
| Professional | | $4.97 | $5.20 | $5.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.48 / $4.97 / $6.96
| Professional | | $3.48 | $4.97 | $6.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.70 / $3.95 / $5.47
| Professional | | $2.70 | $3.95 | $5.47 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.38 / $4.13 / $4.73
| Professional | | $3.38 | $4.13 | $4.73 |